EMS, Gaining Access and Extrication


Article Author:
Jacob Ginglen


Article Editor:
Harrison Tong


Editors In Chief:
Ron Feller
Grant Goold
Kyle Cohen


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/25/2019 7:29:32 AM

Introduction

Emergency medical service (EMS) provides patient care in a variety of settings, from calm to chaotic. EMS providers frequently face challenges in gaining access to patients to provide care, and also in extricating patients from the scene for transport. An example is a motor vehicle crash, where patients are often trapped in mangled vehicles. A less obvious example is the removal of an obese patient from a residence of a hoarder or the rescue of a victim who fell through the ice. A variety of techniques are used to remove the patients from their entrapment, and the appropriate technique depending on the situation. The essential focus for EMS providers, regardless of the situation or scene, is personal safety.[1][2][3][4]

Issues of Concern

The primary concern for EMS providers of all levels on all scenes is personal safety. An EMS provider is of no use to a patient if he or she is injured or incapacitated. More importantly, EMS can be a dangerous job, and providers must ensure that they go home safe at the end of every shift.

Ensuring scene safety begins at dispatch. From the time an EMS crew is notified of a call, they should be conscientious of potential dangers associated with the scene. For example, a vehicle crash scene provides many significant dangers, from fires or downed electrical wires to broken glass or passing traffic. EMS crews should park strategically to avoid traffic, always use emergency lighting when parked on a road or other potentially dangerous scene, and wear reflective clothing to increase visibility. Even with these precautions, motor vehicle crash scenes still present a danger to emergency medical technicians (EMTs) and paramedics, so situational awareness is paramount. In addition, airbags that do not go off with the initial impact may deploy during extrication or patient care. While airbags save lives during a crash, when deployed later, they may cause devastating injuries or even death. EMS providers should be aware of this potential hazard as they work accident scenes.

Scenes not involving car crashes and roads still have the potential for danger, so crews should never let their guard down. Violent patients, family members, and bystanders should be considered by EMS. Crews should never enter a scene that is not secure or has the potential for violence until law enforcement has ensured safety. Still, other dangers exist and must be considered, including chemical hazards such as carbon monoxide.

The appropriate method for gaining access and extricating patients depends on the scenario, but some basic principles apply to all situations. Any structure involved should be stabilized. For example, an overturned car requires support to prevent it from changing position, which could endanger both the patient and the EMS crew. Multiple techniques and pieces of equipment exist for this purpose, ranging from basic wood block cribbing to pneumatic airbags to sophisticated strut systems. EMS personnel must be familiar with what the equipment used by their agency and be comfortable with deploying it. In the event of a fire, explosion, or earthquake, EMS providers should not enter a structure until its integrity can be verified. 

Once the structure has been deemed sound, EMS must gain access to assess and treat the patient; remembering to try the simplest route first. A good phrase to remember is "try before you pry." In other words, before you use force to open a door on either a car or a residence, first check the door. It may be unlocked, and getting to the patient is as simple as turning the knob. If the door is locked or inoperable from damage, then a forceful entry is necessary. A variety of tools and techniques exist for this. Whenever possible, law enforcement should be involved to ensure safety. The risks and benefits of forcing entry must be weighed, and should only be performed when there is a reason to believe the patient is in imminent danger. Depending on the EMS agency and its capabilities, a forceful entry may be the task of a mutual aid agency, such as the fire department. Hydraulic tools, such as spreaders and cutters, commonly referred to by the general public as the "jaws of life," are often used to gain access to patients trapped by mangled metal, such as in a motor vehicle crash. Another popular device commonly utilized by the fire service is the Halligan bar, which combines a blade, a claw, and a tapered pick into one convenient tool. This device gives its user a great deal of leverage, and it is especially useful for opening or breaking through locked residential doors.

While the exact process for forceful entry to a car may differ based on equipment and situation, the overall concepts remain the same. Glass in windows can be taped in a criss-cross pattern before it is broken to minimize the pieces that fall into the car onto the patient. A gap can be created between the door and the frame near the handle with a Halligan bar or other similar tool. Hydraulic spreaders can then be inserted into the gap, and then used to spread the door from the frame. If the door needs to be entirely removed from the vehicle, the same process can be used at the hinge of the door after it is initially opened.

Gaining access may only be step one. Sometimes EMS may obtain access to the patient and begin treatment. However, if the patient remains trapped and cannot be transported to the hospital for definitive care. The process for removing these patients from their entrapment, extrication, can be complex and poses dangers to the patient and EMS. This is particularly important in significant trauma, such as major car accidents, as this may consume a large portion of the critical first hour of trauma care. EMS should provide whatever care they can to the entrapped patient safely, such as airway management or intravenous (IV) fluid administration. During the process of removing the patient from the situation, care should be taken to minimize movement of the spine to prevent worsening of any possible injuries. Cervical collars should be placed as soon as is feasibly possible when a cervical spine injury is suspected. Long spine boards are frequently used to move patients while maintaining alignment of the spine during extrication. Short spine boards also exist for this purpose.

In motor vehicle crashes, patients may become trapped as the dash collapses down, pinning their legs. In this instance, delays in care are compounded as EMS first must gain access to the patient and then must extricate him from the entrapment. Some care can be provided after access is gained, but transport must wait for extrication. Hydraulic tools are typically used to lift the dash in these cases with a technique referred to as the dash roll. Again, EMS providers should be familiar with the capabilities and tools used by their agency.

In some situations, the roof of the car may need to be removed to extricate the patient. The windows must first be removed to accomplish this. Then, the metal support posts between the windows are cut with hydraulic cutters or similar tools. Depending on the needs for extrication, all of the posts can be cut and the roof lifted off the car, or the front 2 to 4 posts can be cut, and the roof can be folded up and backward. To facilitate easy folding, a cut in each side of the roof at the desired folding point may be necessary.

Before performing any automotive extrication technique, providers should take a hands-on course. There are many intricacies to automotive extrication that cannot be covered in this article. EMS personnel should only perform techniques they are trained to perform and should be familiar with their equipment. Specific guidelines and regulations are provided by the National Fire Protection Agency, an agency that governs the fire industry.

Extrication may also be required in industrial or farming accidents. As in other incidents, the specific method for extrication will vary depending on the situation. EMS agencies should be aware of hazards within their communities, where such accidents may occur. For example, grain bins in farming communities present a unique danger. Entrapment in grain bins can quickly become fatal, and extrication is complex and dangerous. In communities with this potential, EMS agencies should practice and plan for grain bin rescues. Courses may be available to learn these techniques. If the complexity of extrication exceeds an agency's capabilities, it should not hesitate to request assistance from an appropriate mutual aid agency, such as a technical rescue squad.

In extreme circumstances, a patient may require a field amputation to be extricated and transported for definitive care. This is only used as last resort when the patient would otherwise die if they cannot immediately be freed. In these situations, contact with medical control is vital. Be familiar with the agency's protocols for this situation.

Some EMS systems utilize physicians in the prehospital setting. In these situations, physicians may be able to provide advanced care to the entrapped patient, until extrication can be completed. EMS systems with this capability should consider utilizing it, especially when prolonged extrication may be expected. Physicians providing this service should also practice scene safety and only perform extrication activities they have been trained to perform.

Clinical Significance

Understanding the prehospital environment is extremely useful for the emergency department clinicians. The scene of a traumatic injury can be chaotic, and understanding what the patient experienced before arriving in the emergency department can improve communication between the emergency department clinician and EMS, which may lead to more efficiency and improved care. The clinician must understand that delays often occur between the incident and arrival to the hospital. This is extremely important in trauma resuscitation when the time is of the essence. Extrication may be a traumatic process of its own, complicating the clinical picture.

EMS provides essential care in the prehospital setting. Providing that care while maintaining personal safety is imperative. EMTs and paramedics should also understand the importance of time during a trauma. Gaining access and extrication should be performed as quickly and efficiently as is safely possible. Ultimately, patients would never arrive in the emergency department without the dedication and hard work of EMS, who provide the critical intervention of extrication.[5][6][7][8]


  • Image 6115 Not availableImage 6115 Not available
    Contributed by the Public Domain
Attributed To: Contributed by the Public Domain

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

EMS, Gaining Access and Extrication - Questions

Take a quiz of the questions on this article.

Take Quiz
Emergency medical services (EMS) is dispatched to a residence for a female who has reportedly fallen down a flight of stairs and is experiencing neck pain. EMS arrives on the scene and discovers it is a one-story modular home. A male is waiting at the door. He directs the crew to a back bedroom, where a female is laying on the bed. She states, "He threw me down and my neck popped." What is the most appropriate next step for the EMS crew to perform?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Emergency medical services (EMS) are requested to a call for a person in distress. Local law enforcement is also dispatched, and arrive on the scene with EMS. When EMS knocks on the door of the residence, there is no answer. A person can be seen through a window, laying on the floor, apparently unconscious. What is the most appropriate next step for EMS?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Emergency medical services (EMS) is requested to the scene of a motor vehicle crash with injuries. On arrival, the crew finds a single vehicle on its side with a female patient in the car, frantically screaming for help. Which of the following is the most appropriate next step for EMS?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Your emergency medical services (EMS) crew has been requested to a remote farm for a report of a person trapped in a grain bin. No one on your crew has ever been trained for grain bin rescue. On arrival, you are directed to a grain bin where bystanders say a farmer fell into the grain. What is the best course of action for your crew?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Emergency medical services is dispatched to the scene of a head-on collision between two vehicles. After arriving on the scene, the crew ensures that the scene is safe and that the vehicles are stabilized. A driver of one of the vehicles is being treated. The driver's door opens easily, but the patient is trapped by the dash pinning his legs on the seat. Care is initiated with a cervical collar and intravenous access. What is the best step to extricate this patient from his entrapment?

(Move Mouse on Image to Enlarge)
  • Image 6216 Not availableImage 6216 Not available
    Credit Holmatro, USA Written permission given from owner
Attributed To: Credit Holmatro, USA Written permission given from owner



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

EMS, Gaining Access and Extrication - References

References

Pietsch U,Strapazzon G,Ambühl D,Lischke V,Rauch S,Knapp J, Challenges of helicopter mountain rescue missions by human external cargo: need for physicians onsite and comprehensive training. Scandinavian journal of trauma, resuscitation and emergency medicine. 2019 Feb 13;     [PubMed]
Koser BW,Lee BH, EMS, Care In A Hostile Environment 2018 Jan;     [PubMed]
Jawaid S,Cody D, Crowbar impalement: the PHEM perspective. BMJ case reports. 2018 Dec 9;     [PubMed]
Vincent-Lambert C,Mottershaw T, Views of emergency care providers about factors that extend on-scene time intervals. African journal of emergency medicine : Revue africaine de la medecine d'urgence. 2018 Mar;     [PubMed]
Reay G,Rankin JA,Smith-MacDonald L,Lazarenko GC, Creative adapting in a fluid environment: an explanatory model of paramedic decision making in the pre-hospital setting. BMC emergency medicine. 2018 Nov 15;     [PubMed]
Stroop R,Schöne C,Grau T, Incidence and strategies for preventing sustained hypothermia of crash victims during prolonged vehicle extrication. Injury. 2018 Oct 24;     [PubMed]
Li T,Cushman JT,Shah MN,Kelly AG,Rich DQ,Jones CMC, Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehospital and disaster medicine. 2018 Oct;     [PubMed]
Issa SF,Nour MM,Field WE, Utilization and Effectiveness of Harnesses and Lifelines in Grain Entrapment Incidents: Preliminary Analysis. Journal of agricultural safety and health. 2018 May 7;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of EMS-Paramedic. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for EMS-Paramedic, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in EMS-Paramedic, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of EMS-Paramedic. When it is time for the EMS-Paramedic board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study EMS-Paramedic.